ATI RN
Introduction to Critical Care Nursing 8th Edition Questions
Question 1 of 5
Why is air drawn into the syringe for a Z-track injection?
Correct Answer: B
Rationale: The correct answer is B because adding air into the syringe creates a barrier that prevents the drug from flowing back into the needle track after injection, ensuring that the medication stays in the intended tissue site. This technique helps minimize tissue irritation and potential leakage of the medication. The other choices are incorrect because: A) Adding air does not decrease pain; C) The Z-track technique itself ensures the solution stays in the muscle, not air; D) Adding air does not ensure the client receives the entire dose, as the focus is on preventing backflow of the drug.
Question 2 of 5
Raymond is a 5-year-old with chronic disease. He had just undergone insertion of central venous catheter via ultrasound. Which of the assessment data should you look first prior to administration of IV fluids?
Correct Answer: D
Rationale: The correct answer is D: Chest radiology results. This is the most critical assessment data to look at first before administering IV fluids to Raymond. By checking the chest radiology results, we can ensure that the central venous catheter is properly placed without any complications such as pneumothorax or malposition. This step is crucial for safe IV fluid administration. A: Serum osmolality and B: Serum electrolyte levels are important assessments but are not as immediate as checking the catheter placement. C: Intake and output record is important for monitoring fluid balance but does not take precedence over confirming the catheter placement.
Question 3 of 5
To determine how long the nasogastric tube must be to reach the stomach of the patient, the nurse should hold the end of the tube:
Correct Answer: C
Rationale: Rationale for Correct Answer (C): 1. Holding the end of the nasogastric tube from the tip of the nose to the tip of the earlobe ensures proper placement. 2. This measurement aligns with the anatomical landmarks for the correct positioning of the tube into the stomach. 3. The tip of the earlobe to the xiphoid process correlates with the distance required for the tube to reach the stomach accurately. Summary of Incorrect Choices: A. Holding from the tip of the nose to the base of the neck is incorrect as it does not provide the accurate distance to reach the stomach. B. Holding from the tip of the nose to the middle of the cheek to the xiphoid process is incorrect as it includes an unnecessary measurement of the cheek. D. Holding eight to ten inches from the tip of the nose to the sternum is incorrect as it does not consider individual variations in anatomy.
Question 4 of 5
In intravenous therapy, the rule is to use veins of the upper extremities first. The superficial veins of the dorsal aspect of the hand are the preferred site. Which area of the wrist is highly sensitive and most painful site of venipuncture and must be avoided by the nurse?
Correct Answer: D
Rationale: The correct answer is D: Inner aspect. This area of the wrist has a higher concentration of nerve endings, making it more sensitive and prone to causing more pain during venipuncture. It is essential for the nurse to avoid this area to prevent unnecessary discomfort and ensure successful venipuncture. The other choices (A: Outer aspect, B: Upper aspect, and C: Lower aspect) do not have the same high sensitivity and pain potential as the inner aspect, making them less critical to avoid during venipuncture.
Question 5 of 5
A client has been receiving an I.V. solution. What is an appropriate expected outcome for this client?
Correct Answer: B
Rationale: Correct Answer: B Rationale: 1. The client remaining free of signs and symptoms of phlebitis indicates that the I.V. site is not infected or inflamed, ensuring proper infusion. 2. Phlebitis can lead to complications such as infection and thrombosis if not managed promptly. 3. Monitoring for phlebitis is crucial to prevent further complications and ensure the client's safety. 4. Options A, C, and D do not directly address the expected outcome of maintaining the client free of phlebitis symptoms.